Israel Medical Association Journal

This paper describes "Health Value Added" – an innovative model that links performance measurement to strategy in health maintanance organizations. The HVA[1] model was developed by Maccabi Healthcare Services, Israel’s second largest HMO[2], with the aim of focusing all its activities on providing high quality care within budgetary and regulatory constraints. HVA draws upon theory and practice from strategic management and performance measurement in order to assesses an HMO’s ability to improve the health of its members. The model consists of four interrelated levels – mission, goals, systems, and resources – and builds on the existence of advanced computerized information systems that make comprehensive measurements available to decision makers in real time. HVA enables management to evaluate overall organizational performance as well as the performance of semi-autonomous units. In simple terms, the sophisticated use of performance measures can help healthcare organizations obtain more health for the same money.

Background: With the introduction of surgery and percutaneous balloon valvuloplasty for relieving severe mitral stenosis the natural history of the disease has markedly altered.

Objectives: To determine the natural history of patients with moderate mitral valve stenosis.

Methods: Demographic, clinical and echocardiographic data were evaluated in 36 patients with moderate mitral stenosis during a follow-up of 71 ± 15 months.

Results: The 36 patients comprised 32 women and 4 men with a mean age of 43.7 ± 12.2 years; 28 were Jewish and 8 were of Arab origin. During follow-up, there was a significant decrease in mitral valve area, with an increase in mean mitral valve gradient and score. Mean loss of mitral valve area was 0.04 ± 0.11 cm²/year. No correlation was found between disease progression and age, past mitral valve commissurotomy, baseline mean gradient or mitral valve score. Larger baseline mitral valve area (P = 0.007) and Arab origin (P = 0.03) had an independent correlation to loss of mitral valve area. Fifteen patients (42%) did demonstrate any loss in mitral valve area during the follow-up period.

Conclusions: The rate of mitral valve narrowing in patients with moderate mitral stenosis is variable and cannot be predicted by patient’s age, past commissurotomy, valve score or gradient. Secondly, larger baseline mitral valve area and Arab origin showed an independent correlation to loss of mitral valve area; and finally, in many patients valve area did not change over a long observation period.
 

During September 2002, Israel began its current revaccination program against smallpox, targeting previously vaccinated “first responders” among medical and emergency workers. In order to identify the potential strengths and weaknesses of this program and the conditions under which critical decisions were reached, we conducted a SWOT analysis of the current Israeli revaccination program, designed to identify its intrinsic strengths and weaknesses, as well as opportunities for its success and threats against it. SWOT analysis – a practical tool for the study of public health policy decisions and the social and political contexts in which they are reached - revealed clear and substantial strengths and weaknesses of the current smallpox revaccination program, intrinsic to the vaccine itself. A number of threats were identified that may jeopardize the success of the current program, chief among them the appearance of severe complications of vaccination. Our finding of a lack of a generation of knowledge on smallpox vaccination urgently calls for improved physician education and dissipation of misconceptions that are prevalent in the public today.

Background: Pterygium is a common disease in Israel. Different surgical techniques are used to manage it with varying degrees of success.

Objectives: To evaluate the efficacy and safety of a conjunctival autograft after excision of pterygium.

Methods: Excision followed by conjunctival autograft was used to treat 40 eyes of 40 patients with pterygium. The surgical results were evaluated retrospectively. Follow-up continued for a median of 296 days (range 6±1,056); 26 cases were followed for more than 100 days (average 418 days) and comprised the study cohort. All reported procedures were performed consequentially and by one surgeon in the Tel Aviv Sourasky Medical Center, Israel between 1 June 1997 and 31 March 2000.

Results: There were two recurrences of pterygium (2/26, 7.7%) 2 months postoperatively. There were no major complications. Super-ficial corneal vessels (without concurrent fibrosis) appeared in 10 of 17 cases sutured with nylon, but none occurred in any of the seven grafts sutured with vicryl (P = 0.068). The average LogMAR-corrected visual acuity of the study group improved slightly, from 6/16.5 to 6/11 (P = 0.003).

Conclusions: Excision of pterygium with a conjunctival autograft is a safe and effective operation, with no procedure-specific added surgical risks. The relatively long surgical time and microsurgical methods required to perform the procedure properly have hindered its acceptance as the mainstream approach to pterygium management. Long-term follow-up is needed for better discernment of the surgical results in Israel.
 

Background: Decreased heparan sulfate proteoglycan content of the glomerular basement membrane has been described in proteinuric patients with diabetic nephropathy. Heparanase is an endo-b-D-glucuronidase that cleaves negatively charged heparan sulfate side chains in the basement membrane and extracellular matrix.

Objectives: To investigate whether urine from type I diabetic patients differs in heparanase activity from control subjects and whether resident glomerular cells could be the source of urinary heparanase.

Methods: Using soluble ³⁵S-HSPG[1] and sulfate-labeled extracellular matrix we assessed heparanase activity in human glomerular epithelial cells, rat mesangial cells, and urine from 73 type I diabetic patients. Heparanase activity resulted in the conversion of a high molecular weight sulfate-labeled HSPG into heparan sulfate degradation fragments as determined by gel filtration analysis.

Results: High heparanase activity was found in lysates of both epithelial and mesangial cells. Immunohistochemical staining localized the heparanase protein to both glomeruli capillaries and tubular epithelium. Heparanase activity was detected in the urine of 16% and 25% of the normoalbuminuric and microalbuminuric diabetic patients, respectively. Urine from 40 healthy individuals did not posses detectable heparanase. Urinary heparanase activity was associated with worse glycemic control.

Conclusion: We suggest that heparanase enzyme participates in the turnover of glomerular HSPG. Hyperglycemia enhances heparanase activity and/or secretion in some diabetic patients, resulting in the loss of albumin permselective properties of the GBM[2].

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[1] HSPG = heparan sulfate proteoglycan

[2] GBM = glomerular basement membrane

Background: Although Listeria monocytogenes is widely distributed in nature, it rarely causes clinical infection in previously healthy people. This microorganism. however, may cause severe invasive disease in pregnant women and newborns.

Objectives: To investigate – in our pregnant population – the impact, severity and outcome of listeriosis on both mother and fetus.

Method: The study was carried out at a level III, university two-hospital complex, In a retrospective chart review of 65,022 parturients during a 10 year period (1990-1999), we identified and: evaluated 11 pregnant patients and their offspring with Listeria infection;

Results: Chorioamnionitis with multiple. placental abscesses were observed in all five placentae examined. Clinically 4 of 11 parturients had a cesarean section for fetal distress (36.3%), as compared to the 14% mean CS rate in our general population. Two of 11 had a fate abortion (18.1%), as compared with the 4% rate in our hospital. Four of 11 had premature labor (36%), which was about four times the rate in our population. Finally, although no intrauterine feta1 death was recorded in our series, there was one neonatal death of a term infant. (1/11, 9%), which is about 10 times higher than our corrected perinatal mortality rate.

Conclusions: If not promptly and adequately treated, listeriosis in pregnancy may present serious hazards to the fetus and newborn through direct infection-of the placenta and chorioamnionitis.
 

Background: Eldercare often necessitates the presence of a family caregiver at the senior's visit to a doctor’s office. Studies indicate that some caregivers are not satisfied with these encounters or with as An understanding of the dynamics of these complex interactions is required.

Objectives: To explore family physicians’ attitudes to interfacing family caregivers of the elderly, to identify factors within the family patient-caregiver encounters in the office setting that for physicians,  to ascertain factors that might be problematic for physicians, to ascertain factors that might contribute to doctors’ behaviors and concerns, and to propose possible solutions for optimizing the outcomes of these visits.

Method: A questionnaire for self-administration was mailed to 200 family physicians in Montreal, Canada who are affiliated with two community secondary care and one tertiary care hospital and involved in geriatric office practice. The survey focused on family physician attitudes, concerns and observations on the interactions among themselves, elderly patients and their family caregivers during office visits.

Results: A total of 142 completed questionnaires were returned with a 71% response rate. Most family doctors felt that it was their responsibility to respond to caregiver concerns (90.6%) and that they were generally meeting their needs (94.2%). In contrast, 81% found this activity stressful and that as few as three such encounters per day were sufficient to generate stress. Causes of stress included: a) concern regarding misdiagnosis, b) different agendas or conflicting responses of patient and caregiver to doctors’ suggestions, and c) reluctance of the elderly or the caregiver to use community resources. A common physician strategy was reliance on acquired professional experience to solving problems of the elderly or of their caregivers.

Conclusions: Despite the stress involved, physicians are interested in assisting caregivers in the management of the elderly. Many doctors lack adequate knowledge about or confidence in community resources. Clinicians may require enhanced skills in conflict resolution necessary to achieve optimal outcomes.

Fanconi anemia is a rare autosomal recessive disorder characterized clinically by congenital abnormalities, progressive bone marrow failure, and a predisposition to malignancy. FA cells are sensitive to DNA cross-linking agents. Complementation analysis of FA cells using somatic cell fusion has facilitated the identification of eight complementation groups, suggesting that FA is a genetically heterogeneous disorder. Six genes (FANCA, FANCC, FANCD2, FANCE, FANGF, FANCG) have been cloned so far. The majority of affected patients belong to FA group A. Of the 32 unrelated Israeli patients with FA that we studied, 6 carried the FANCC mutations and 15 the FANCA mutations. Among the Jewish patients, ethnic-related mutations were common. Recent cumulative evidence suggests that the FA proteins are repair proteins. FANCC, FANCA and FANCG bind and interact in a protein complex found in the cytoplasm and nucleus of normal cells. FANCD2 exists in two isoforms; the long active form, FANCD2-L, is absent from FA cells of all complementation groups. FANCD2 co-localized with BRCA1 in unclear foci, probably as part of a large genomic surveillance complex. Studies using FANCA and FANCC knockout mice suggest that bone marrow precursors express interferon-g hypersensitivity and show progressive apoptosis. The definition of the molecular basis of FA in many affected families now enables prenatal diagnosis.

Background: Previous studies have shown a low prevalence of diabetes and other cardiovascular risk factors among Bedouins living in the Negev Desert. New evidence suggests that diabetes is becoming highly prevalent.

Objectives: To estimate the prevalence of diabetes in the town of Rahat, describe the cardiovascular risk factor profile and therapeutic modalities for diabetes and related conditions in this population, and compare these findings with those in the Jewish population.

Methods: A complete record review of all known diabetic individuals aged 35 and older registered at the Rahat Clinic (Clalit Health Services) was carried out by a trained nurse and a research assistant. Information on demographic, anthropometric and clinical characteristics was abstracted. Data on prescribed hypoglycemic agents and other medications were also obtained.

Results: Of the 316 known diabetic patients in the clinic, complete data were available for 271 (85.8 %). The prevalence of known diabetes was 7.3% in males and 9.9% in females. Females had a significantly higher body mass index than males (30.9 vs. 29, P < 0.002), but lower levels of HBA1c and microalbuminuria. Oral hypoglycemic medications were taken by 69% of women and 76% of men, and insulin by 19% of women and 15% of men.

Conclusions: Compared with data on Jewish diabetic patients in the Negev and Israel, the overall prevalence of diabetes in the population of Rahat is higher, but their cardiovascular risk profile is better, except for obesity. These findings support the hypothesis that diabetes and obesity have become major public health problems among Bedouins.
 

Background: The implementation of treatment guidelines is lacking worldwide.

Objectives: To examine whether follow-up in a specialized lipid clinic improves the achievement rate of the treatment guidelines, as formulated by the National Cholesterol Education Program and the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.

Methods: The study group included patients who were referred to the lipid clinic because of hyperlipidemia. At each of five visits over a 12 month period, lipid levels, liver and creatine kinase levels, body mass index, and adherence to diet and medications were measured, and achievement of the NCEP[1] target level was assessed.

Results: A total of 1,133 patients (mean age 61.3 years, 60% males) were studied. Additional risk factors for atherosclerosis included hypertension (41%), type II diabetes mellitus (21%), smoking (17%), and a positive family history of coronary artery disease (32%). All patients had evidence of atherosclerotic vascular disease (coronary, cerebrovascular or peripheral vascular diseases). The low density lipoprotein target of <100 mg was present in only 22% of patients before enrollment, with improvement of up to 57% after the follow-up period. During follow-up, blood pressure control was improved (from 38% at the time of referral to 88% after 12 months, P < 0.001), as was glycemic control in diabetic patients (HgA₁C improved from 8.2% to 7.1% after 12 months, P < 0.001). Improved risk factor control was due to increased compliance to medication treatment (from 66% at enrollment to more than 90% after 12 months), as well as careful attention to risk factor management that translated into a change in the treatment profile during the follow-up. There was an increase in the use of the following medications: aspirin from 68% to 96%, statins from 42% to 88%, beta blockers from 20% to 40%, and angiotensin-converting enzyme inhibitors from 28% to 42%; while calcium channel blocker use decreased from 40% to 30% in patients during follow-up.

Conclusion: Follow-up of patients in a specialized clinic enhances the achievement of LDL[2]-cholesterol treatment goals as well as other risk factor treatment goals, due to increased patient compliance and increased use of medications.

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